Liberalized diet in patients with type 1 diabetes

OBJECTIVE

To document that strict dietary regimen are not necessary in the context of intensified insulin therapy.

DESIGN

German multicentre, prospective cohort study; 6 years follow-up.

SETTING

Ambulatory examination using a mobile ambulance.

SUBJECTS

A total of 636 type 1 diabetic patients (age 33 +/- 7 years, diabetes duration 15 +/- 7 years; mean +/- SD), who had participated in a structured, 5-day, in-patient, group treatment and teaching programme for intensification of insulin therapy and liberalization of the diabetes diet 6 years prior to follow-up.

MAIN OUTCOME MEASURES

Relations between the extent to which patients practise a liberalized diet, the degree of metabolic control (HbA1c, severe hypoglycaemia, body mass index, cholesterol), and the patients' perceived burden through dietary treatment.

RESULTS

In the total patient group, HbA1c was 7.9 +/- 1.6%, and the incidence of severe hypoglycaemia was 0.17 cases per patient during the preceding year; 31% patients injected insulin < or = 3 times per day, 58% 4-7 times per day, and 11% used insulin pump therapy. Only 11% patients reported following a meal plan, whereas 89% continually changed timing and amount of carbohydrate intake; only 5% had the same number of meals every day, whereas as many as 20% varied the number of meals per day by four or more; 53% skipped main meals; 85% habitually consumed sugar or sugar containing foods. Patients with a higher degree of diet liberalization injected insulin or used an insulin pump therapy more frequently, and perceived their dietary treatment to be less burdensome. No clinically significant associations were found between the extent of diet liberalization and metabolic control.

CONCLUSIONS

Under the conditions where type 1 diabetic patients have the opportunity to participate in an intensified insulin treatment and teaching programme, liberalization of the diabetes diet is not associated with adverse effects on glycaemic control, but is associated with less perceived burden through dietary treatment.

Cancer vaccines: the interleukin 2 dosage effect

Cancer vaccines genetically engineered to produce interleukin 2 have been investigated intensively in a series of animal models and are at the point of entering into clinical trials. In this study we demonstrate a strong correlation between the rate of interleukin 2 production and the protection efficiency of murine S91 melanoma cell (clone M-3) vaccines. Best immunization is achieved with vaccines producing medium interleukin 2 levels of 1000-3000 units per 10(5) cells per day. Reduced interleukin 2 production evokes a corresponding decline in the number of successfully treated animals. Unexpectedly, when interleukin 2 expression is raised to high levels of 5000-7500 units per 10(5) cells per day, protection is completely absent because of impaired generation of tumor-specific cytotoxic T lymphocytes. In comparison, granulocyte-macrophage colony-stimulating factor as immunomodulator induces substantial immunization even at a moderate level of secretion and protects all animals at the maximal obtainable level of secretion. Our findings demonstrate the importance of the interleukin 2 level produced by genetically modified tumor cells and may have substantial impact for the clinical application of cancer vaccines.

A seizure, and electroencephalographic signs of a lowered seizure threshold, associated with fluvoxamine treatment of obsessive-compulsive disorder

A 38-year-old patient with severe obsessive-compulsive disorder received fluvoxamine in a clinical study. Psychometric ratings showed marked clinical improvement in the third week of fluvoxamine administration, but after 8 weeks, at a dose of 300 mg per day, he suffered a grand mal seizure after drinking a glass of beer (0.2 liter). He had no history of previous epileptic seizures. Careful neurological evaluation including computer tomography and magnetic resonance imaging of the brain revealed no signs of acute disease. EEG before the fit did not show epileptiform activity; after the fit, spikes and spike-wave complexes appeared, which disappeared upon discontinuation of fluvoxamine. Since his obsessive-compulsive symptoms had responded well to fluvoxamine and worsened after its discontinuation, the drug was cautiously reintroduced. Improvement of the obsessive-compulsive symptoms was observed again, but spikes and spike-wave complexes reappeared at a dose of 50 mg per day. Under anticonvulsant treatment with carbamazepine, fluvoxamine was increased to 100 mg per day. No seizures occurred during a follow-up to two years.

[Pathogenetic factors of Alzheimer disease]

The aim of this article is to review the pathogenetic factors of Alzheimer's disease. Primary correlates of Alzheimer's disease are a dysfunction of and a subsequent decrease in the number of cortical and hippocampal synapses, followed by neurofibrillary and neuritic changes of hippocampal and cortical neurons. While the synapse pathology has been shown to be an early event in Alzheimer's disease, a significant neurofibrillary and neuritic pathology appears to develop only during the course of the disease. Cortical amyloid deposits are an unspecific, age-related phenomenon that can also be found in the brains of the majority of nondemented elderly persons over the age of 65 years. Transgenic amyloid mice proved to be of only limited value as animal models of Alzheimer' disease. According to several studies, there is no correlation between the total number of cortical amyloid plaques and clinical parameters of dementia. However, such a correlation exists with respect to the proportion of neuritic plaques, i.e., with respect to the degree of neuritic degeneration within plaques. In addition to these changes, an interleukin-6 associated inflammatory response has been found in the cortices of Alzheimer patients which is absent in the brains of nondemented elderly persons, and which therefore appears to be a specific element. The significance of changes in the cholinergic neurotransmission for Alzheimer's disease is discussed. Finally, the role of apolipoprotein E and other genetic risk factors is reviewed. In this context it is emphasized that in young persons apolipoprotein E4 is not a suitable early diagnostic marker for Alzheimer's disease.

Growth-hormone response to clonidine in panic disorder patients in comparison to patients with major depression and healthy controls

Growth-hormone (GH) responses to the alpha 2-adrenoceptor agonist clonidine were measured in 9 panic disorder patients, in 9 patients fulfilling DSM-III-R criteria for major depressive episode, and in 9 age- and sex-matched controls. GH responses to clonidine were not significantly different between the groups. The data do not agree with the assumption that blunted GH responses to clonidine represent a general feature of panic disorder or major depression.

Elicitation of a systemic and protective anti-melanoma immune response by an IL-2-based vaccine. Assessment of critical cellular and molecular parameters

We have established a model for the immunologic rejection of melanoma cells. Using a receptor-mediated, adenovirus-augmented gene delivery system (transferrinfection) we have shown that, upon transfection with an IL-2 gene construct, MHC class I+/class II- murine M-3 cells lose their tumorigenicity in both athymic and euthymic mice. More importantly, we found that these melanoma cells, which produce high levels of IL-2, can be used to induce a long-lasting anti-tumor immune response in syngeneic euthymic DBA/2 mice but not in athymic animals. This immune response, which can also be elicited by coadministration of nonmodified, irradiated M-3 cells and IL-2-transduced fibroblasts, results in the rejection of a subsequent challenge with M-3 cells or, in the elimination of preexisting M-3 cancer cell deposits. We found that transfer of T cell-enriched, but not of T cell-depleted, splenocytes from immunized mice conferred protection against M-3 cells, but not against unrelated KLN 205 cancer cells. Transfer of either CD4+ or CD8+ T cells led to only partial protection against challenge with wild-type M-3 cells. Our further observations that T cell-enriched, but not T cell-depleted splenocytes of immunized animals are capable of tumor-specific lytic activity and that this activity resides in the CD8+ cell population are compatible with the assumption that MHC class I-restricted T cell cytotoxicity is a biologically relevant effector mechanism in this model. That other mechanisms also contribute to melanoma cell destruction is evidenced by the presence of large numbers of macrophages and granulocytes in addition to T cells at the challenge sites of immunized mice.

Marked PR interval prolongation simulating ST-segment elevation during exercise testing. A case report

ST-segment elevation during exercise testing is usually indicative of severe proximal coronary artery disease. In this report, the authors describe a patient who underwent exercise stress testing and developed apparent ST elevation in the inferolateral leads. However, noninvasive imaging studies revealed no evidence of myocardial ischemia or other recognized causes of this exercise electrocardiographic (ECG) finding. Analysis of the ECG tracings showed that ST elevation was produced by marked prolongation of the PR interval, super-imposing the P wave on the J-junction of the preceding QRS-ST-segment complex. The authors suggest that marked PR prolongation during exercise may mimic ST elevation, and this possibility should be considered in patients with this exercise ECG finding in whom cardiac evaluation is negative.

Elicitation of a systemic and protective anti-melanoma immune response by an IL-2-based vaccine. Assessment of critical cellular and molecular parameters

We have established a model for the immunologic rejection of melanoma cells. Using a receptor-mediated, adenovirus-augmented gene delivery system (transferrinfection) we have shown that, upon transfection with an IL-2 gene construct, MHC class I+/class II- murine M-3 cells lose their tumorigenicity in both athymic and euthymic mice. More importantly, we found that these melanoma cells, which produce high levels of IL-2, can be used to induce a long-lasting anti-tumor immune response in syngeneic euthymic DBA/2 mice but not in athymic animals. This immune response, which can also be elicited by coadministration of nonmodified, irradiated M-3 cells and IL-2-transduced fibroblasts, results in the rejection of a subsequent challenge with M-3 cells or, in the elimination of preexisting M-3 cancer cell deposits. We found that transfer of T cell-enriched, but not of T cell-depleted, splenocytes from immunized mice conferred protection against M-3 cells, but not against unrelated KLN 205 cancer cells. Transfer of either CD4+ or CD8+ T cells led to only partial protection against challenge with wild-type M-3 cells. Our further observations that T cell-enriched, but not T cell-depleted splenocytes of immunized animals are capable of tumor-specific lytic activity and that this activity resides in the CD8+ cell population are compatible with the assumption that MHC class I-restricted T cell cytotoxicity is a biologically relevant effector mechanism in this model. That other mechanisms also contribute to melanoma cell destruction is evidenced by the presence of large numbers of macrophages and granulocytes in addition to T cells at the challenge sites of immunized mice.

Effects of the serotonin-1A agonists buspirone and ipsapirone on field potentials in the hippocampus slice: comparison with carbamzepine and verapamil

The serotonin-1A agonists buspirone (BU) and ipsapirone (IPSA) have been demonstrated to exert antidepressant and anxiolytic effects. Since some antidepressant drugs and the antiepileptic substance carbamazepine have calcium antagonistic properties, the interaction of BU and IPSA with carbamazepine and the organic calcium channel blocker verapamil was analyzed in the low Mg2+ induced model epilepsy which has been shown to be suppressed specifically by organic calcium antagonists. BU and IPSA reduced the frequency of occurrence of low magnesium induced field potentials in CA1 and CA3 areas of the hippocampus slice preparation (guinea pigs) in a dose dependent manner. The subthreshold concentrations which yielded no effect were 5 mumol/l for BU and IPSA, 10 mumol/l for carbamazepine and 2 mumol/l for verapamil. Combinations of these subthreshold concentrations elicited a reduction in the repetition rate of field potentials. The results indicate that BU and IPSA behave additively with verapamil and carbamazepine, which may be due to a common action on the same subtype of calcium channels. It may be assumed that besides their action on 5-HT1A receptors BU and IPSA may also have calcium antagonistic properties.

Outcome at three years of sick neonates involved in a double-blind trial of two parenteral amino acid preparations

The authors investigated the hypothesis that neonates who received a parenteral amino acid preparation causing high plasma amino acid levels in the first week of life would perform less well at follow-up than those who received a preparation in which the plasma aminogram fell persistently within the normal range. 27 surviving children who had received either preparation as neonates underwent psychometric assessment at three years. Parents completed three questionnaires about temperament, behaviour screening and socio-economic status. Four of 10 patients who had received one preparation and two of 17 infants who had received the other were of below-average intelligence. This may be related to the different amino acids in the mixtures and the hyperamino-acidaemia caused by this.

[Treatment of panic disorders and agoraphobia. Psychotherapy, psychopharmacotherapy and their combination]

During the last two decades substantial progress has been achieved in the development and evaluation of effective treatment approaches to panic disorder and agoraphobia. Many clinical research studies in this area were begun after the definition of operationalized diagnostic criteria for panic disorder and agoraphobia in the DSM-III in 1980. Different concepts concerning the etiology, pathogenesis and maintaining factors of these disorders are still controversial. At the beginning of this controversy, psychopharmacological treatment was believed to suppress spontaneous panic attacks while behavioral treatment mainly focused on anticipatory fears and avoidance behavior. Meanwhile both treatment approaches have proved their effectiveness in reducing panic attacks and agoraphobia. Therefore, it was hypothesized that a combination of both individual treatments could enhance therapeutic efficacy. The few studies examining this question did not allow clear conclusions because of methodological shortcomings. In the short run, there seems to be a trend for better results with combined treatment. In the long run, however, combined therapy has not been observed to be superior to cognitive-behavioral therapy without any psychopharmacological support. In practice, adverse side effects restrict the application of psychopharmacological approaches. On the other hand, qualified cognitive-behavioral therapists are not always available, or patients are referred to them by general practitioners and psychiatrists after a delay. Criteria for the application of behavioral therapy, psychopharmacological therapy and their combination are proposed and discussed.

Implementation of intensified insulin therapy: a European perspective

The Diabetes Education Study Group (DESG) of the European Association for the Study of Diabetes (EASD) was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. Within the DESG, a number of models for structured diabetes treatment and teaching programmes were developed. Concerning the care of persons with Type 1 diabetes, substantial emphasis was placed upon the 5-day in-patient treatment and teaching programme for groups of 6 to 10 patients as originally introduced at the University of Geneva and further developed for general use at the University of Düsseldorf. During the early 1980s, this programme was based upon intensified insulin therapy including a stepwise liberalization of previously rigid rules for nutrition and life schedules. In several European centres the programme was continuously evaluated and shown to be effective as documented by significant reductions of glycated haemoglobin values, episodes of ketoacidosis, hospitalizations, and sick-day leaves. In contrast to the Diabetes Control and Complications Trial (DCCT) the improvement of glycated haemoglobin values was not associated with an increased risk of severe hypoglycaemia. Possible reasons for this favourable outcome are discussed. During recent years the 5-day treatment and teaching programme for Type 1 diabetes has been translated into the general health care system of Germany without any loss of its efficacy. In addition, in various other European countries, model centres of diabetes care have implemented the 5-day programme, and for a number of these centres, its efficacy to improve the overall quality of diabetes care has been published or presented at meetings.

Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child

In order to improve the basis upon which to advise women with diabetic nephropathy about pregnancy, we studied the effect of diabetic nephropathy on the course of pregnancy, perinatal outcome, infant development and long-term outcome of the mothers. All pregnancies of women with diabetic nephropathy (defined as proteinuria > 400 mg/day (n = 26), creatinine clearance < 80 ml/min and hypertension in the first trimester (n = 10)) followed at our centre from 1982 to 1992 were identified (34 White class F and 2 White class T) and the women and their children re-examined in the spring 1993. From the first to the third trimester the percentage of women with proteinuria over 3 g/day increased from 14 to 53% and those treated with antihypertensive medication from 53 to 97%. There were no intrauterine or perinatal deaths, but one child died suddenly 4 weeks postpartum. Of 36 newborns (gestational week at birth 36(3), birth weight 2384(834) g)), 11 were born before week 34 and 8 had respiratory distress syndrome. Renal function in the first trimester, diastolic blood pressure in the third trimester and an HbA1c above normal were predictive of gestational age at delivery and low birth weight (stepwise regression analysis). At follow up of the children (n = 35, age 4.5 (0.4-10) years) the majority (n = 27) were normally developed but seven had psychomotor retardation (four of them major). One child had a severe motor retardation due to a congenital anomaly. At follow up, 21 of the 29 mothers had preserved renal function (creatinine 1.3 (0.8-4.3) mg/dl and 8 had developed end stage renal disease and required dialysis (2 of whom were White class T) within 3 (1-9) years postpartum.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of 4-hour hyperglycaemia and hyperinsulinaemia on plasma atrial natriuretic factor concentrations

To elucidate the mechanism behind the increased plasma atrial natriuretic factor (ANF) reported in Type 1 diabetic patients with glomerular hyperfiltration and incipient nephropathy, we studied the effects of a short-term moderate hyperglycemia with concomitant hyperinsulinaemia on plasma ANF concentrations and glomerular filtration rate (GFR) in healthy male volunteers. Following a 2-hour basal run-in period, blood glucose level was clamped at 12.2 mmol/l for 4 hours by infusing 20% glucose solution (hyperglycaemia study) or the level was kept normal by infusing isotonic saline over the 4 hours (saline control study). Plasma ANF increased slightly both in the hyperglycaemia phase (from 25.7 +/- 6.3 to 32.1 +/- 7.5 ng/l at 3 hours [p < 0.02] and 31.0 +/- 6.6 ng/l at 4 hours [p = 0.058, mean +/- SD]) and in the control phase (from 17.7 +/- 6.1 to 26.1 +/- 13.5 ng/l at 3 hours [p < 0.05] and 25.4 +/- 11.7 ng/l at 4 hours [p < 0.05]) as compared with the respective baseline values. GFR remained unchanged both in the hyperglycaemia (from 108 +/- 8 to 104 +/- 13 ml/min/1.73 m2) and the saline control phases (from 106 +/- 7 to 101 +/- 7 ml/min/1.73 m2), respectively. The results of this short-term study showed no association between the moderate hyperglycaemia with a concomitant hyperinsulinaemia and plasma ANF concentration in non-diabetic normotensive subjects.

Tumor vaccines: effects and fate of IL-2 transfected murine melanoma cells in vivo

We have previously demonstrated the general usefulness of the adenovirus-enhanced transferrinfection (AVET) in the generation of IL-2 producing tumor vaccines. By optimizing different parameters of the transfection protocol we were able to transform the poorly immunogenic M-3 mouse melanoma cell line into a potent immunogen. A long-lasting immunity was demonstrated after administration of the IL-2 releasing vaccine, since immunized animals successfully rejected native M-3 melanoma cells even after a period of more than 6 months. We also demonstrated that in vivo administration of such a vaccine is safe since transmission of the transfected IL-2 gene in host organs was not detected. IL-2 production ceased 2 days after injection because the engineered cells were destroyed. However, RT-PCR analysis of the site of vaccine injection suggests that IL-2 exerts its effects not only directly but also by inducing a set of other immunomodulator cytokines in situ that are probably indispensable in inducing a host response. We conclude that AVET of IL-2 into tumor cells is a safe and efficient method for the generation of tumor vaccines.

Mental comorbidity of chronic insomnia in general practice attenders using DSM-III-R

The major aim of this study was to investigate links between chronic insomnia and mental and personality disorders using the DSM-III-R classification. Of a sample of 2512 general practice attenders, 105 with a chronic insomnia complaint over a 4-month period were evaluated for mental and personality disorders. In addition, the significance of other factors such as personality traits, social functioning and the patient's own estimation of sleep quality was studied. Sixty-six patients got a diagnosis of a current insomnia using a structured interview for DSM-III-R. Fifty percent of them had at least one additional current Axis I or II diagnosis. Affective disorders were most common as principal psychiatric diagnosis followed by substance use disorders. The general practitioners were poor in recognizing their patients' chronic insomnia complaints and the high percentage of substance abusers among them. The important role of psychopathology in chronic insomnia sufferers was indicated by the high number of patients who displayed prominent personality traits. The predominant personality pattern was characterized by a pattern of internalization of problems combined with an anxious-depressive reaction style. In summary, strong associations between chronic insomnia, mental disorders and psychopathology were confirmed by this investigation.

A calcium antagonist for the treatment of depressive episodes: single case reports

Preclinical studies indicate that a disturbed intracellular calcium ion homeostasis is involved in the pathophysiology of affective disorders. Therefore some calcium antagonists were investigated, especially in the treatment of the manic syndrome. In the present study the calcium antagonist nimodipine was used in 10 out-patients with single or recurrent depressive episodes. As a result the mean HAMD scores changed from 26.5 to 9.9 after the individual nimodipine administration. These single case reports suggest an effective new therapy strategy for the treatment of affective dysregulations and give rise to controlled clinical studies with calcium antagonists.

Pacemaker infection

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Interleukin-6 is present in early stages of plaque formation and is restricted to the brains of Alzheimer's disease patients

Interleukin-6 (IL-6) immunoreactivity has previously been shown in plaques in Alzheimer's disease (AD) and elevated IL-6 concentrations have been measured biochemically in brains of AD patients. In this study, we investigated the appearance of IL-6 immunoreactivity in AD plaques according to the stage of plaque formation. Using the Bielschowsky silver-staining method, we were able to differentiate between four types of plaques described earlier: diffuse, primitive, classic and compact. While diffuse plaques represent the early stage of plaque formation, primitive and classic plaques are thought to represent later stages of plaque development. We investigated serial sections of paraffin-embedded cortices of ten clinically diagnosed and histopathologically confirmed AD patients and ten patients with no clinical history of dementia. We found plaques in the brains of both nondemented and demented persons using the silver staining method or immunohistochemistry with antibodies against the amyloid precursor protein. In the group of clinically nondemented persons, diffuse plaques were the predominant plaque type, whereas primitive plaques formed the larger portion of lesions in the group of AD brains. IL-6 could not be detected in plaques of patients without dementia. Many IL-6-positive plaques were found in six of the AD brains and to a smaller extent in the other four AD cases. In the six cases with a large number of IL-6-positive plaques, IL-6 was found in a significantly higher ratio of diffuse plaques than expected from a random distribution of IL-6 in all plaque types.(ABSTRACT TRUNCATED AT 250 WORDS)

[Depression and sleep--the status of current research]

Abnormalities of REM sleep, i.e. shortening of REM latency, lengthening of the duration of the first REM period and heightening of REM density, which are frequently observed in patients with a Major Depressive Disorder (MDD), have attracted considerable interest. Initial hopes that these aberrant patterns of sleep constitute specific markers for the primary/endogenous subtype of depression have not been fulfilled. The specificity of REM sleep disinhibition for depression in comparison to other psychopathological groups is also challenged. Demographic variables like age and sex exert strong influences on sleep physiology and must be controlled when searching for specific markers of depressed sleep. It is still an open question whether abnormalities of sleep are state-markers or trait-markers of depression. Beyond baseline studies, the cholinergic REM induction test (CRIT) indicated a heightened responsitivity of the REM sleep system to cholinergic challenge in depression compared with healthy controls and other psychopathological groups, with the exception of schizophrenia. A special role for REM sleep in depression is supported by the well known REM sleep suppressing effect of most antidepressants. The antidepressant effect of selective REM deprivation by awakenings stresses the importance of mechanisms involved in REM sleep regulation for the understanding of the pathophysiology of depressive disorders. The positive effect of total sleep deprivation on depressive mood which can be reversed by daytime naps, furthermore emphasizes relationships between sleep and depression. Experimental evidence as described above instigated several theories like the REM deprivation hypothesis, the 2-process model and the reciprocal interaction model of nonREM-REM sleep regulation to explain the deviant sleep pattern of depression. The different models will be discussed with reference to empirical data gathered in the field.

Exercise echocardiographic correlates of transient dilatation of the left ventricular cavity on exercise thallium-201 SPECT imaging

Transient dilatation of the left ventricular cavity on exercise thallium perfusion imaging is recognized as a marker of significant coronary disease, but the mechanisms that produce this finding are not fully understood. We studied 32 patients who underwent exercise thallium imaging and exercise echocardiography to determine the changes in left ventricular cavity size that underlie transient dilatation. Left ventricular area from the apical four-chamber view was used to approximate left ventricular cavity size. There were 24 patients who did not have transient dilatation (group 1) and 8 patients who did have transient dilatation (group 2) on thallium imaging. Systolic area decreased from rest to exercise in group 1 patients but not in group 2 patients. There was no significant change in diastolic area from rest to exercise in either group 1 or group 2 patients. Thus, exercise-induced systolic dysfunction, manifested as a failure to decrease left ventricular systolic cavity size in exercise, may be an important mechanism in producing scintigraphic transient dilatation.